Navigating Pediatric Ataxia in the Emergency Department

Show Notes

Introduction

• The episode focuses on ataxia in children, which can range from self-limiting to life-threatening conditions.
• Pediatric emergency medicine specialist shares insights on the topic.

The Case

• An 18-month-old boy presented with ataxia, unable to keep his head up, sit, or stand, and began vomiting.
• Previously healthy except for recurrent otitis media and viral-induced wheezing.
• The decision to take the child to the emergency department (ED) was based on acute symptoms.

Differential Diagnosis

• Common causes include acute cerebellar ataxia, drug ingestion, Guillain-Barre syndrome, and basilar migraine.
• Less common causes include cerebellitis, encephalitis, brain tumors, and labyrinthitis.

Importance of History and Physical Examination

• A detailed history and physical exam are essential in diagnosing ataxia.
• Key factors include time course, recent infections, signs of increased intracranial pressure, and toxic exposures.
• Look for signs such as bradycardia, hypertension, vomiting, and overall appearance.

Diagnostic Workup

• Initial tests include point-of-care glucose and neuroimaging for concerns about trauma or increased intracranial pressure.
• MRI is preferred for posterior fossa abnormalities, but non-contrast head CT is commonly used due to accessibility.
• Lumbar puncture may be needed if meningismus is present.

Treatment Approach

• Treatment depends on the underlying cause:
  • Acute cerebellar ataxia is self-limiting and typically resolves with time.
  • Antibiotics are required for meningitis or encephalitis.
  • Steroids may be useful for cerebellitis and acute disseminated encephalomyelitis (ADEM).
  • Specialist consultations are necessary for severe diagnoses like intracranial masses.

Outcome of the Case Study

• The child had a normal fast T2 MRI and improved during the ED stay.
• Diagnosed with a combination of cerebellar ataxia and labyrinthitis.
• Received myringotomy tubes and experienced no further neurologic changes or otitis media episodes.

Take-Home Points

1. Diverse Etiologies:  Ataxia in children can have various causes that range from self-limiting to life-threatening
2. Comprehensive Assessment: History and physical exams guide diagnosis and workup direction, focusing on symptom time course, infections, and toxic exposures.
3. Physical Examination Clues: Vital signs and appearance offer clues; increased ICP may present with bradycardia, hypertension, and vomiting.
4. Diagnostic Imaging: Point-of-care glucose testing and neuroimaging are key; MRI is preferred for posterior fossa abnormalities.
5. Tailored Treatment: Treatment varies by cause; acute cerebellar ataxia typically resolves over time without specific intervention.